Basic Information
| Provider Information | |||||||||
| NPI: | 1871920702 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LUMINIS HEALTH MEDICAL GROUP, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RIVER FAMILY PHYSICIANS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12622 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434816524 | ||||||||
| FaxNumber: | 4434816515 | ||||||||
| Practice Location | |||||||||
| Address1: | 28438 MARLBORO AVE | ||||||||
| Address2: | |||||||||
| City: | EASTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216012732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108207270 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2013 | ||||||||
| LastUpdateDate: | 02/15/2022 | ||||||||
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| AuthorizedOfficialLastName: | ODENWALD | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4434816415 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.